Pharmacies have an obligation to check the status of patients but they insist they ‘don’t want to be the prescription police’.
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The letter came out of the blue. Headed NHS Business Services Authority (NHSBSA), it accused Charles Brooks* of wrongly claiming a free prescription and demanded the £17.60 charge for his two asthma inhalers plus an £88 penalty. But Brooks had paid.

He appealed with a copy of his bank statement to prove he had paid and the demand was dropped. Two months later he received another £88 penalty plus the £17.60 charge. Again, he was accused of having wrongly claimed exemption. As before, he had paid at the pharmacy, but this time he used cash so he was unable to prove it.

“Online, I found many other people being unjustly sent these penalties,” he says. “The stress is huge …my wife is ill and my son has autism. Being accused of something that is basically fraud is scary. ”

Patients who are exempt from the £8.80 prescription charge have to show their exemption certificate or tick a box on the prescription form. In a bid to clamp down on fraud, which costs £256m a year, the NHS performs random checks after the medicine or treatment has been dispensed. Patients who are suspected of wrongly claiming face a penalty of five times the prescription charge plus the charge itself. The maximum is £100; £50 is added if the bill is not settled within 28 days.

At the end of 2014, responsibility for the checks was transferred from local NHS trusts to the NHSBSA and since then the number of penalties has doubled from 494,129 to over 1m in 2017. However, while the £13m in penalties recouped losses from those who defrauded the system that year, many are being penalised for a pharmacy error or because of a misunderstanding. A third of the 2017 penalties were overturned on appeal.

The NHSBSA told the Observer that pharmacists have a contractual obligation to check the status of patients and submit accurate forms, but it’s the patient who takes the rap if they get it wrong.

Louise Staniforth faced a £44 penalty because staff at Superdrug’s online service had wrongly ticked the box claiming that she held a valid exemption certificate.

Because her prescription was sent direct from her GP, she had no chance to check the form. “I assumed Superdrug had debited my account and didn’t realise I hadn’t paid,” she says. “I don’t understand how the exemption works as I have never had one, and this has made dealing with the matter incredibly stressful.”

Superdrug told her she should pay up and it would refund the penalty as a “goodwill gesture”, but the cheque only arrived a month later after pressure from the Guardian’s Consumer Champions. Superdrug says that “this incident was an isolated case due to a lapse in process which we take very seriously. It is being thoroughly investigated.”

Meanwhile, low-income patients on universal credit who are exempted from prescription charges are receiving penalty notices because prescription forms have not been amended to include the benefit – six years after it was introduced. Some have reported receiving multiple charge notices.

The NHSBSA says a universal credit tick box should be added “later this year”. Until then, claimants entitled to free prescriptions must tick the “income-based jobseeker’s allowance” box, but some who did so report they have still been penalised.

Many of the patients who receive penalty notices failed to realise that they no longer qualified for free prescriptions and dental treatment. Exemption certificates are automatically issued to those who earn less than £15,276 a year and receive working tax credit, child tax credit or income support.

However, the certificates are only valid for up to seven months and recipients are not notified if they do not qualify for a renewal.

Last year, Labour called for an overhaul of the system when a woman killed herself after receiving nearly £200 in penalty charges. Penny Oliver, a part-time chef, had not realised her exemption had lapsed after an assessment deemed her fit for full-time work. Because her benefits had been cut she could not afford the penalties. In June 2018, she took an overdose of antidepressants – the medication that had racked up the debt.

Single mother Sue Carpenter was ordered to pay £100 after mistakenly claiming a free dental check-up. “I have had an NHS exemption since my daughter was three, but I received no reminder that it would run out when she was 18,” she explains.

“I knew my child tax credit would change, but I’m still eligible for working tax credit and I assumed the exemption was linked to the entire tax credit award, not just to the child component. The dentist didn’t ask to see my certificate, which I now realise expired two weeks before.”

Carpenter says that the expiry date should be made clear. “The NHS exemption seems a unique instance of a status that runs out with no clear warning, allows you to continue using it when it has expired and then incurs a steep penalty without prior notice of the consequences.”

The NHSBSA says it is a patient’s responsibility to check the expiry date on their exemption certificate.

Professional and patients’ bodies have expressed concern that the system to catch fraudsters is undermining the ethos of the NHS.

“Serving penalty notices on patients cannot be a caring way to manage this system,” says Rachel Power, chief executive of the Patients Association. “Some of the people who received these notices will be in vulnerable situations, and the impact of letters threatening court action, particularly for those who are receiving treatment for mental illnesses, should not be underestimated.

“While it’s important that fraudulent and incorrect claims are identified, nearly one in three penalty notices had to be withdrawn because they were issued in error. This shows a system that is highly dysfunctional.”

This year the NHS is piloting a digitised system that will enable pharmacists to check eligibility instantly.

The health secretary, Matt Hancock, has previously said: “The message is clear. The NHS is no longer an easy target, and if you try to steal from it you will face the consequences.”

The Royal Pharmaceutical Society and the British Medical Association fear the new system will withhold vital treatment from people on low incomes who remain eligible for free prescriptions but have failed to renew their paperwork.

“Pharmacists don’t want to be the prescription police, spending their time checking exemptions rather than advising on patient care,” says Sandra Gidley, chair of the Royal Pharmaceutical Society’s English pharmacy board.

“It’s very easy for mistakes to happen. Sometimes it’s that the computer says ‘no’, on other occasions people have simply forgotten to renew. Some don’t know if they’re exempt or not, or wrongly assume they are.”

She says that the prescription system should be overhauled to prevent confusion and reflect medical advances. “Medical exemption criteria have not changed since 1968. This means they are completely unjust. For example, those with long-term asthma have to pay for prescriptions, whereas people with diabetes don’t. Many new long-term conditions have been discovered in the past 50 years and they aren’t covered at all.

“It would be much simpler to have free prescriptions for everyone, as is the case in Scotland and Wales, because then no one would have to worry about remembering to fill out the right form.”